Community Service Reporting Form

This form is to be used by clubs/student organizations, students, faculty, and staff to record community service hours.

This form is to be used by clubs/Student organizations, students, faculty, and staff to record community service hours.

I am reporting as

Contact Information

First Name:

Last Name:

Phone:

Email Address:

University ID Number:

Department/Major:

Contact Information

Name of the Club/Student Organization:

List all members of the Student Organization who participated:

Location/Organization where community service was provided:

Address:

Street:

City:

State:

Zip:

Contact person at location who can verify this service was provided:

First Name:

Last Name:

Phone:

Email Address:

Type of Service:

If you selected "other" above, please tell us what you did:

Number of hours volunteered:

Number of combined hours volunteered:

Date/Dates this service was provided:

Short description of the project:

Thank you for volunteering your time and for reporting your hours.

For any questions please call 203-837-9700 or email diazv@wcsu.edu.